Healthcare Provider Details

I. General information

NPI: 1932600947
Provider Name (Legal Business Name): SUSANA MACIAS M.A. BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2018
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2303 WHISTLER WAY
STOCKTON CA
95209-4157
US

IV. Provider business mailing address

2740 ROSEWOOD AVE
CERES CA
95307-2038
US

V. Phone/Fax

Practice location:
  • Phone: 209-953-8106
  • Fax:
Mailing address:
  • Phone: 209-872-4527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-55325
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-45747
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: